Lab Respiratory NGS Requisition Form

4305 Oakes Road STE 513 Davie, Florida 33314 954-541-3705 www.asaplab.com Respiratory Infection Requisition CLIA# 10D2079014: Lab Director: Dr. Kambiz Yaraei, PhD FACILITY DEMOGRAPHICS PATIENT DEMOGRAPHICS Name: Name: Male Female Address: Phone: DOB: City: State: Zip: Address: Phone: City: State: Zip: Specimen Collection Ancestry (Circle): Date of Collection: Caucasian Eastern European Northern European Time of Collection: Western European Native American Middle Eastern African American Asian Pacific Islander Notes: Caribbean Central / South Other ______ Ashkenazi Jewish American Hispanic Physician Name: NPI: BILLING INFORMATION Bill: (Circle) Insurance HAS Medicaid Medicare Self Pay Workers Compensation Name of Policy Holder: Medicare # Medicaid # Relationship to Policy Holder (Circle) Worker’s Comp Claim # Date of Injury Self Spouse Dependent Other: _____________ Policy # Group # Insurance Company: PATIENT CONSENT MEDICAL NECESSITY Billing ABN and Patient Plan Information: A completed Advance Beneficiary This test is medically necessary for the diagnosis or detection of a disease, Notice (ABN) of coverage is required for Medicare patients who do not meet illness, impairment, syndrome or disorder, and these results will be used in the medical criteria for testing. This does not apply to specific site analyses. medical management and treatment for this patient. Furthermore, recipients’ Insurance pre-qualification will not be performed for these tests, unless information is true and correct to the best of my knowledge. specifically requested. All tests ordered shall be processed and billed based on The person listed as the Ordering Physician or genetic counselor is authorized by payor. law to order the test(s) requested herein. I confirm that I have provided genetic Patient Acknowledgment: I am covered by insurance and authorize ASAP testing information to the patient and they have consented to genetic testing. Lab, LLC to give my designated insurance carrier(s) plan on this form and other information provided by my health care provider necessary for reimbursement. I authorize ASAP Lab, LLC to inform my Plan of my test results only if test results Please check all that apply: are required for preauthorizalion of or payment for reflex/additional testing. I authorize Plan benefits to be payable to ASAP Lab, LLC. I further authorize I confirm that the above patient’s testing is medically necessary and payment of benefits directly to the laboratory. I understand acceptance of the result will be used to assess patient health and for future insurance does not relieve me from any responsibility concerning payment for conditions risk laboratory services and that I am financially responsible for all charges whether I agree to allow ASAP Lab LLC to transfer the information contained or not they are covered by my insurance. I understand that any payment I receive for services rendered by the laboratory from my insurance provider in this requisition to an LMN (Letter of Medical Necessity) using the should be forwarded immediately to the laboratory. The data may also reveal ordering physician’s name as his/her signature for insurance billing secondary or incidental findings, such as that you may be at risk for certain purposes genetic diseases or that you are a carrier of disease associated mutations. I have attached a LMN for insurance billing purposes PATIENT CONAENT: My Signature below constitutes my acknowledgment that Patient meets clinical / genetic testing criteria for the above ordered the benefits, risks, and limitations of this testing have been explained to my tests. satisfaction by a qualified health professional and I have received a copy of the full informed consent document. I have been given the opportunity to ask questions before I sign, and I have been told that I can ask questions at any other time. I voluntarily agree to genetic testing. X Signature of Patient Date X Health Care Provider’s Signature Date TEST SELECTION Coronavirus (Eswab) Next Generation Sequencing COVID-19 / SARS-COV-2 Genetic Lung Disorders – 51 genes (Buccal) ABCA3, ACVRL1, AP3B1, ASCL1, BDNF, BLOC1S3, BLOC1S6, BMPR2, CCDC39, CCDC40, CFTR, DNAAF1, DNAAF2, DNAH11, DNAH5, DNAI1, DNAI2, DNAL1, DTNBP1, EDN3, EFEMP2, ELN, ENG, FBLN5, FLCN, GDNF, HPS1, HPS3, HPS4, HPS5, HPS6, LTBP4, MUC5B, NME8, PHOX2B, RET, RSPH4A, RSPH9, SCNN1A, SCNN1B, SCNN1G, SERPINA1, SFTPA1, SFTPA2, SFTPB, SFTPC, SMAD9, TERC, TERT, TSC1, TSC2 Primary Ciliary Dyskinesia – 38 genes (Buccal) – Chronic Respiratory Infections ARMC4, CCDC103, CCDC114, CCDC151, CCDC39, CCDC40, CCDC65, CCNO, CFAP298, CFTR, DNAAF1, DNAAF2, DNAAF3, DNAAF4, DNAAF5, DNAH11, DNAH5, DNAH8, DNAI1, DNAI2, DNAJB13, DNAL1, DRC1, GAS8, HYDIN, INVS, LRRC6, MCIDAS, NME8, OFD1, PIH1D3, RPGR, RSPH1, RSPH3, RSPH4A, RSPH9, SPAG1, ZMYND10 Bronchiectasis – 16 genes (Buccal) CCDC39, CCDC40, CFTR, DNAAF1, DNAAF2, DNAH11, DNAH5, DNAI1, DNAI2, DNAL1, NME8, RSPH4A, RSPH9, SCNN1A, SCNN1B, SCNN1G ICD – 10 Codes (REQ’D) R05 Cough J01.90 Acute Sinusitis, Unspecified J18.9 Pneumonia, Unspecified Organism R06.02 Shortness of Breath J02.9 Acute Pharyngitis, Unspecified J20.9 Acute Bronchitis, Unspecified R50.9 Fever, Unspecified J06.9 Acute Upper Respiratory Infection, Unspecified J32.9 Chronic Sinusitis, Unspecified Pneumonia (COVID-19) Acute Bronchitis (COVID-19) Bronchitis (COVID-19) J12.89 Pneumonia, Other viral pneumonia J20.8 Acute Bronchitis, Unspecified J40 Bronchitis, Unspecified B97.29 Pneumonia, Other coronavirus B97.29 Pneumonia, Other coronavirus B97.29 Pneumonia, Other coronavirus Lower Respiratory Infection (COVID-19) Z03.818 Suspected exposure to COVID-19 Z20.828 Known Exposure to COVID-19 R09.81 Congestion Z15.89 Genetic Susceptibility to Other Disease Addtl: .

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